Scalp repair using tissue expanders.

Repair of scalp defects is often challenging, because without careful planning, excision of the defect may leave unsatisfactory cosmesis. Contemporary techniques in hair restoration surgery allow creation of natural and undetectable results, but these techniques are often unsuitable for repairing large scarred areas of hair loss. However, by using older techniques of scalp reduction and tissue expansion, excision of many large scarring defects can be accomplished. Combining older methods with modern hair restoration surgery permits the satisfactory treatment of many previously untreatable conditions. This article focuses on tissue expansion as an adjunct to repairing large scalp defects.

Should we use stents in subarachnoid hemorrhage?

Based on findings from the International Subarachnoid Aneurysm Trial (ISAT), coiling of ruptured cerebral aneurysms is associated with the lowest immediate morbidity and mortality rates compared to other treatment options.1, 2 Whenever anatomy permits, coiling is the preferred method for repair. Unfortunately, not all cerebral aneurysms are suitable for coiling, and the best treatment for aneurysms that cannot be coiled remains unclear. Adjunctive techniques such as surgical clipping, balloon remodeling,3 use of two microcatheters,4 and intracranial stents 5 can increase the likelihood of aneurysm thrombosis and parent vessel patency. The goal of this article is to describe our current practice using intracranial stents in appropriately selected patients with subarachnoid hemorrhage (SAH) as a result of aneurysm rupture.

Scalp reconstruction and repair.

Reconstruction and repair of scalp deformities poses several challenges. The repair and/or removal of the existing defect is often difficult; however, the appearance of the repair is often the most difficult challenge. Thus, an understanding of normal hair morphology, anatomy, and physiology is important to achieve long-lasting, satisfying results. We must anticipate future hair loss, communicate that to the patient, and consider it in surgical planning. In addition, residual effects such as radiation therapy after cancer resection may pose additional challenges. Today, many extraordinary techniques are available that allow creation of natural and almost undetectable hairlines, but these techniques are often unsuitable for repairing large scarred areas of hair loss. By using more traditional techniques of scalp reduction and tissue expansion, however, excision of many large scarring defects can be accomplished. Combining older methods with modern hair restoration surgery permits the satisfactory treatment of many previously untreatable conditions.

Basal ganglia lesions after MPTP administration in rhesus monkeys.

In monkeys, intracarotid infusion of a single low dose of MPTP reliably induces a hemiparkinsonian syndrome that is stable over time. This model has been widely used to assess novel anti-parkinsonian therapies. Here, we report the exceptional finding of severe necrotic lesions that were observed in the basal ganglia (but not in the substantia nigra) of monkeys that received a single intracarotid injection of MPTP followed by gene therapy treatments. Although extensive unilateral dopaminergic nigrostriatal loss was found in all the animals, partial behavioral recovery was observed in the subjects that presented pallidal necrotic lesions. This report discusses possible causes and effects of the necrotic lesions and their locations and the value of the intracarotid MPTP model. Testing novel therapies in monkey models has become an essential step before clinical trials. These results indicate that evaluation of any treatment should consider possible confounding factors that may affect the results.

Core curriculum for hair restoration surgery, recommended by the International Society of Hair Restoration Surgery (ISHRS).

BACKGROUND: Because hair restoration surgery (HRS) has changed so significantly, the International Society of Hair Restoration Surgery (ISHRS) presents the recently developed Core Curriculum for Hair Restoration Surgery (CCHRS). Physician competence in HRS demands a sound understanding of all of the alternate pathologic causes of hair loss, as well as their risks and treatments. OBJECTIVE: The CCHRS defines the knowledge, didactic information, medical insights, and surgical techniques that are essential to physician competence in the correct diagnoses and treatment of hair loss problems, in a manner consistent with patient safety and sound esthetic results. The ISHRS hopes that all existing surgical and dermatology training programs that teach HRS procedures will find the CCHRS useful in developing their curriculum relative to HRS and that this will facilitate the development of a new standard of training within the profession. METHODS: Developed and reviewed by a committee of experienced hair restoration surgeons. RESULTS: The CCHRS clearly defines the diagnosis and treatment of hair loss as a multidimensional specialty requiring knowledge of several medical disciplines, including genetics, endocrinology, dermatology, and surgery. CONCLUSION: The ISHRS believes that the CCHRS is an important contribution to physician education in HRS and that a clearly defined core curriculum will facilitate achieving contemporary results and higher patient satisfaction.

Hair deformities.

To be able to treat the wide spectrum of hair deformities, a surgeon must possess a wide spectrum of skills in HRS, cosmetic surgery, and reconstructive surgery. Specific education and training in HRS is not a traditional part of formal surgical training, although much information is available through several national and international organizations. Being sensitive to the unique variables associated with HRS increases the chances of achieving a superior functional and cosmetic result when treating significant hair deformities.

A comparison of the trauma score, the revised trauma score, and the pediatric trauma score.

We compared the abilities of the Trauma Score (TS), the Revised Trauma Score (RTS), and the Pediatric Trauma Score (PTS) to retrospectively identify severely injured children. TS, RTS, and PTS were computed on admission for 1,334 consecutive blunt and penetrating trauma victims 0 to 14 years old. Injury Severity Score values of more than 15 and 20 or more were used as the criteria indicating severe injury. Sensitivity, specificity, and positive and negative predictive values were computed. Threshold values were determined for each scale to maximize sensitivity and specificity. No significant differences were found between the TS and the PTS. After adjusting for rapid respirations among children 0 to 3 years old, no differences existed between the RTS and the other scores. TS of less than 15, RTS of less than 12, and PTS of less than 9 are equally sensitive and specific indicators for pediatric prehospital triage. Because of the similarity of the instruments tested, their performances in other areas, such as quality assurance, should be considered when selecting a pediatric triage tool.

Trauma score versus revised trauma score in TRISS to predict outcome in children with blunt trauma.

We analyzed the accuracy of TRISS and a revised TRISS to predict survival outcome in a group of 1,562 consecutive children less than 15 years old admitted with blunt trauma to a pediatric trauma center. TRISS is an index that computes a probability of survival for each patient based on Trauma Score, Injury Severity Score, and age. R-TRISS uses the Revised Trauma Score instead of the Trauma Score. We used a statistical method based on TRISS and R-TRISS to compare patient outcomes from the pediatric study group with those of an adult baseline control group from the Major Trauma Outcome Study. Both TRISS and R-TRISS have the capability to accurately quantify survival outcome for children with blunt trauma; there was no statistical difference between the two methods to do so.

Outcome analysis of blunt injury in children.

A group of 1,009 children less than 15 years of age and consecutively admitted to a Pediatric Trauma Center was used to compare outcomes with the adult (15-54 yrs) MTOS norm population using TRISS. Four pediatric age groups (0-1, 0-3, 0-8, 0-14 yrs) formed the study groups. TRISS analysis resulted in no statistically significant difference in predicted outcome between any of the four pediatric groups and the adult baseline group. There were only seven misclassified children (0.69%) with respect to survival/death outcome, indicating the usefulness of TRISS to characterize pediatric blunt trauma. In addition, TRISS was used to delineate the injury severity mix of the pediatric population. A TS less than or equal to 14 and ISS greater than 15 was found to serve as a useful definition of severity in this group of injured children.

Comparative outcomes of children and adults suffering blunt trauma.

In order to test the hypothesis that outcome from blunt traumatic injury is different for children and adults, a statistical method based on the TRISS Index was used to compare patient outcomes after blunt injury among three pediatric populations (N = 594 children: ages 0-3, ages 0-8, and ages 0-14) and an adult population (N = 7,809: ages 15-54 inclusive). There was no statistical difference in predicted outcome between these populations. Using a methodology that accounts for both anatomic injury description and physiologic response (TRISS), the survival probability function does not appear to be age dependent below 54 years.

A pediatric emergencies training program for emergency medical services.

Accidents are the leading cause of death in children, accounting for more pediatric deaths than all other causes combined. Accidents also account for 21.7 million injuries to children that require medical care annually. Despite recognition of this major public health problem, little emphasis is directed toward the pediatric patient in emergency medical services education. In response to this need, Children's Hospital National Medical Center developed a three-day training program in pediatric emergencies for field emergency medical technicians, intermediate paramedics, and paramedics. The course consists of 18 hours of lectures and skill stations focusing on medical emergencies, care of the injured child, the special needs of the infant, and the emotional response of the child and family in an emergency. Test evaluations before and after the course from the 190 participants demonstrate a significant improvement in their knowledge and skills in treating pediatric emergencies (P less than 0.001).

Loss of hand and forearm following Bier block: a case report.

Few complications have been reported with the use of the Bier block for intravenous regional anesthesia. The method requires little expert training and produces good analgesia in a bloodless field for a period of 1 to 1.5 hours. The loss of an upper extremity in a 25-year-old white woman who had the performance of a Bier block for removal of a ganglion cyst is reported. The block was performed with 200 mg of mepivacaine without epinephrine. Total tourniquet time was 25 minutes. The patient had prompt onset of pain and swelling followed by loss of motor and sensory function. Operative exploration revealed necrosis of the forearm compartments. Arteriography demonstrated thrombosis of the terminal branches of the radial and ulnar artery. Below elbow amputation was performed 1 week later. Essentially all complications reported with regional anesthesia have been related to the systemic pharmacologic effects of the local agent used. Loss of an upper extremity has not been reported. We postulate three possible mechanisms: (1) possible cannulation and injection of the radial artery, (2) an idiosyncratic allergic reaction to the anesthetic agent or the preservative, and (3) erroneous injection of a foreign substance into the forearm venous system. We conclude the last mechanism is the most likely cause in this patient.

Analysis for potassium in human erythrocytes by use of a standard-additions method and an ion-selective electrode.

A method based on standard additions to the sample was used to measure potassium (K+) in human erythocytes with an ion-selective electrode. A computer program was developed for rapid analysis of data obtained with the electrode. The analysis takes into account factors such as temperature that may affect electrode behavior. Results obtained by the method agree with those obtained by flame-emission spectroscopy. The coefficient of correlation between the two methods is 0.96. Our method is simple and rapid. The computer program is applicable to other analyses with ion-selective electrodes.